The Indian government announced on July 11, 2012, at the London Summit for Family Planning that it has brought about “a paradigm shift” in its approach and will emphasize promotion and provision of contraceptives for birth spacing. The Indian government announced that its new strategy focuses on “making contraceptives available at the doorstep through 860,000 community health workers,” providing services for inserting intrauterine devices (IUDs) on fixed days in public health facilities, and improving post-natal services for IUDs, especially in those public health facilities that have large numbers of women coming to give birth. But the ongoing focus of the Indian central and state governments on achieving numerical targets for use of contraception, especially female sterilization, has contributed to a coercive environment for several decades, and should not be replicated going forward.

Unless India’s approach to contraception is revised, community health workers may come under increased pressure to meet contraceptive targets, the rights groups said. The government’s plans should ensure that all community health and nutrition workers give women adequate information about HIV prevention, sterilization, and other contraceptive choices.

Two years after the 1994 International Conference on Population and Development, India announced that it would take a “target-free” approach to family planning. Since then, the Indian government has stopped setting centralized targets. But in practice, state-level authorities and district health officials assign targets for health workers for every contraceptive method, including female sterilization.

In much of the country, authorities aggressively pursue targets, especially for female sterilization, by threatening health workers with salary cuts or dismissals. As a result, some health workers pressure women to undergo sterilization without providing sufficient information, either about possible complications, its irreversibility, or safer sex practices after the procedure.

“Health workers who miss sterilization targets because they give proper counseling and accurate information about contraception risk losing their jobs in many parts of the country,” said Aruna Kashyap, women’s rights researcher at Human Rights Watch. “The Indian government should work with civil society to ensure that mechanisms to monitor progress in contraceptive use emphasize quality and respect for reproductive rights.”

In June, Human Rights Watch interviewed more than four dozen Female Health Workers and early childhood careand nutrition workers, called anganwadiworkers, andAccredited Social Health Activists (ASHA) from two districts in Gujarat state about their family planning work in rural areas, as well as various health experts. Both Gujarat districts have large adivasi(indigenous tribal) populations, which are among the most impoverished groups in the state.

More than 50 health workers told Human Rights Watch that district and sub-district authorities assigned individual yearly targets for contraceptives, with a heavy focus on female sterilization. Almost all said that their supervisors or other higher-ups threatened them with adverse consequences if they did not achieve their targets.

These included threats to withhold or reduce salary, negative performance assessment, or suspension and dismissals. In one case, a health worker reported that she was asked to falsify records to show she had met targets or else she would be reported for poor performance. One women’s rights organization that has more than a decade of experience working with community health workers in various parts of Gujarat confirmed that state and district health authorities have consistently set such targets and threatened health workers.

Experts from across India have repeatedly voiced concerns about contraceptive targets leading to coercion and poor quality services. This was highlighted during state-level consultations and a national conference hosted by the Family Planning Association of India in New Delhi in June. At that conference, experts reiterated their decades-long demand for contraceptive choice and better quality services instead of a focus on numbers of people accessing contraceptives or undergoing female sterilization.

“Information about contraceptive choice and quality of services should not be sacrificed for numbers,” said Dr. SundariRavindran, steering committee member of the CommonHealth Coalition. “Hounding a poor woman to get sterilized without proper information and leaving her to deal with negative reproductive health consequences cannot be seen as success.”

State authorities in some parts of India also use incentives – including cars, gold coins, and drawings for prizes – to “promote” sterilization. Because male sterilization is not well-accepted socially, this almost always means female sterilization. The most recent District Level Household and Facility Survey from 2008shows that of the 54 percent of the population that reported using any method of contraception, female sterilization accounted for 34 percent and male sterilization accounted for 1 percent of contraceptive use.

Aside from family planning programs, sterilization is pursued through other programs that are entirely funded by state governments. For example, five states have introduced “girl child promotion” programs, which provide monetary benefits to parents of girls, with a final cash benefit if she reaches the age of 18 unmarried. But to receive benefits, a couple must produce a sterilization certificate.

Experts have repeatedly called for the Indian central government to refashion its family planning program to take into account social factors related to childbearing, including early marriage, the preference for sons, infant and child mortality, and the country’s lack of social security for the elderly.

The Indian central government’s failure to implement social security programs has been a major deterrent to contraceptive use since many families say they rely on their children, especially sons, to care for them in old age. India created a National Policy for Older Persons in 1999 and passed the Maintenance and Welfare of Parents and Senior Citizens Act, 2007. But little has been done to implement the policy and law.Indian experts participating in the Delhi conference pointed out that pursuing an agenda of sterilization without addressing old age security only increases the risk of illegal sex-selective abortions.

“Son preference and choices about birth are intrinsically linked to fears about old age insecurity,” said Dr. Subha Sri, steering committee member of CommonHealth coalition. “By failing to address old age security for the poor, India is both turning its back on families pressured to meet targets and increasing the likelihood of sex-selective abortions.”

India’s family planning program focuses predominantly on women, with little interaction and engagement with men. At the same time, it is men who often decide when to have sex and how many children to produce. For India to be successful in its renewed efforts at family planning, it should engage effectively with men too, the rights groups said.

With early marriage prevalent in many areas and with India having the highest number of adolescents in the world, information about reproductive and sexual health should become an important part of both school curricula and health services for adolescents. India’s 2003 Youth Policy specifically recognized that “information in respect of the reproductive health system should form part of the educational curriculum.” But nearly a decade after the Youth Policy was introduced India has yet to introduce compulsory sex education for adolescents.

“In sex education, there are no shortcuts to engaging with both adolescents and men,” said Dr. Abhijit Das, steering committee member of the National Coalition Against Two Child Norm. “India should treat age-appropriate compulsory sex education – both inside and outside schools ­as integral to its new chapter on family planning and find a way of engaging men effectively.”

As India moves into its new phase of contraceptive services, the Indian government should:

Consult with health rights experts and create a panel to develop measureable indicators for monitoring access to and use of contraceptives beyond numerical targets, which focus on spacing between two consecutive births, informed decision-making, and quality care;

Pilot test a minimum package of integrated sexual and reproductive health services that includes a range of contraceptives and compulsory age-appropriate sexuality education for adolescents in and out of schools;

Set up an independent grievance redress system that includes civil society members to report coercion and poor quality contraceptive services and to facilitate remedial action;

Give priority to training male workers to provide information and counselingto men about safer sex and contraceptive choice;

Review all existing girl-child promotion schemes, direct state governments to revise these schemes to stop forcing sterilization as the primary contraceptive method, and develop guidelines for such schemes.

Examine the issue of social security for the elderly as an issue of national priority and take measures to review and implement the National Policy on Older Persons.

For details of the findings of Human Rights Watch’s research in Gujarat state, statements of health workers, and information about India’s family planning program, please see below.

Pressure for Female Sterilization and IUDs; Threats and Incentives
In June, Human Rights Watch interviewed health workers about family planning practices in two districts in Gujarat. More than 50 health workers said that each of them was assigned individual targets for family planning services, including female sterilization and insertion of IUDs, that they were expected to meet every year. Almost all said that their supervisors or other higher-ups inappropriately pressured them with threats to achieve such targets.

Threats to Meet Sterilization Targets
Five Female Health Workers interviewed by Human Rights Watch said that each of them, together with their male counterpart (called a Multipurpose Health Worker), had to ensure that at least 30 women were sterilized annually. They delegated meeting this target partly to ASHAs, the community health workerswho helped “motivate” women to undergo sterilization. At the village level, anganwadi workers also said they had sterilization targets to achieve and were expected to speak to women they knew.

One angawadi worker, Truptibein (name changed), recalled a planning meeting for anganwadiworkers with their supervisor in April:

Each of us has to bring five women for operation [sterilization] in one year, the CDPO [Child Development Project Officer] told us in the meeting. This announcement they make every year… It has been like this almost since the time I was appointed [in the late 1980s]. If we don’t do this, they say they will deduct our salary or that our salary will be stopped.

Truptibein said that when these targets are not met:

They shout at those who have not fulfilled their targets during meetings. It’s humiliating. They say, “If others can achieve the target, why can’t you? You must know some women? You must have relatives or some contacts after working in the villages? Use them and get women operated [sterilized].”

Alokabein(name changed), a municipal corporation community-based health worker (officially called a link worker) who works in a slum in Gujarat told Human Rights Watch:

I have to bring one woman every month for the operation. The MO [medical officer] or my supervisor says, “Go bring them from wherever you want, it’s not our business. Find them. But you must bring one woman for operation every month. If you cannot even bring one woman in a month for operation it means you are not doing your work properly.” They say they will complain about us. [Or] remove us from our jobs if we don’t complete this target. We are told, “Until a woman agrees for the operation keep hounding her.”

To meet targets, health workers said they repeatedly visited women to convince them to get sterilized. Truptibein said, “I have to keep going to women’s houses. Sometimes in one week I go 10 times to one woman’s house.”

Alokabein said:

These government officers and doctors don’t know what it is like to work and live in the same basti [area]. If we don’t get the mother-in-law and husband to agree for sterilization, tomorrow they will create problems for the daughter-in-law and they will all show up in our houses since we live in the community.

Gujarat state is not alone in the practice of threatening to punish health workers who fail to meet sterilization and other family planning targets. The Indian government’s Advisory Committee for Community Action,a health advisory body, reported in 2011 that the Madhya Pradesh state government had suspended health workers for not meeting family planning targets.

Even though Gujarat has established targets for many forms of contraceptives, health workers said pressure from supervisors was strongest when it came to female sterilization. Two health workers said they felt constrained to present women only with the choice of female sterilization and emphasize that option over other methods of contraception. Alokabein said she risked the ire of her supervisor by discussing other contraceptive options:

To fulfill targets they operate [sterilize] really young women—20, 22, 24, 25 years. These women are really young and then their bodies gain weight after a few years and they find it very hard to work... They [supervisors] tell us not to tell women these things. But women can see for themselves that this happens so they are reluctant. So I tell young women to use Copper T [IUD] if they don’t want to go for operation. If my supervisor finds out I’ve been saying this in the slum she will shout at me. Maybe I’ll lose my job, but maybe she won’t be that angry because I can tell her I’ve fulfilled my Copper-T target. But because she doesn’t go to the slum and I make the reports, she doesn’t know all this and I get saved. I feel really bad telling women they should only do operation. This kind of pressure for operation is not correct.

Examples of Threats to Meet IUD Targets
Health workers in Gujarat told Human Rights Watch that they also faced threats and pressure if they did not meet targets for women agreeing to use Copper-T, an IUD.They said that they had an annual target for Copper-Ts, and in some cases were pressured to falsify records to show that the targets were met. Alokabein said she was asked to bring at least three women every month for insertion of the Copper-T:

One month I was not able to fulfill my Copper-T target so my supervisor said, “Don’t you know three women’s names from your slum? Just write three women’s names and give it.” I felt really bad and fought with her. I said “How can I write three women’s names even if they haven’t come for this?” She got really angry with me and told me to just write three names if I did not want to get into trouble for not meeting my target. So I wrote some three women’s names saying they had come for Copper-T.

These problems are not unique to Gujarat. Indian health rights activists have for decades pointed to the flaws in this target-driven incentives-disincentives approach and shown how this approach violates women’s reproductive rights.

Incentives to Meet Sterilization Targets
In addition to threats against health workers, some states have offered “incentives” for sterilization, drawing widespread criticism from Indian civil society. In 2011, the Madhya Pradesh government announced that anyone opting for sterilization would get a Tata Nano car, and at least one district announced gun licensesfor men who agreed to be sterilized.Similarly,several districts in Rajasthan statein 2011 announced lucky draws for couples who opted for sterilization, giving away expensive prizes including cars, bikes, and refrigerators.

Pressure for female sterilization comes up in other government programs beyond family planning. For example, the condition of sterilization is attached to “girl child promotion” programs in five states in India. Associate Professor T.V. Sekher of the Tata Institute of Social Sciences, the author of a United Nations Population Fund-sponsored studyabout Indian programs to promote acceptance of girl children and correct son preference, said that Andhra Pradesh, Karnataka, Madhya Pradesh, Punjab, and Himachal Pradesh state governments had programs in which couples had to produce sterilization certificates to be eligible for benefits (including monetary payments). This led to female sterilization because that was considered more socially acceptable than male sterilization, he said.

Poor Quality Information and Lack of Informed Consent
The quality and nature of information that health workers provide women and their families to convince them to be sterilized is questionable, raising doubts about informed consent, Human Rights Watch found. Sheetalbein (name changed), an ASHA, said, “I tell these women you can get yourself operated. They put rings inside and tie the birth tubes and you can go back to the doctor and take the rings out if you want to have children again.”

This inaccurate information contradicts the 2006 Standards for Female and Male Sterilization, which clearly states that sterilization is difficult and expensive to reverse. The International Federation for Obstetricians and Gynecologists in its 2011 Guidelines for Female Contraceptive Sterilization states that:

Information for consent includes, for instance, that sterilization should be considered irreversible, that alternatives exist such as reversible forms of family planning, that life circumstances may change, causing a person later to regret consenting to sterilization, and that procedures have a very low but significant failure rate.

At least two health workers reported to Human Rights Watch that women came back to them and reported that they wanted to have the sterilization procedure reversed. Several other health workers reported that female sterilization procedures had failed. None of them had discussed these possibilities with women before taking them for sterilization.

Similarly, contrary to Indian central government standardsfor pre-sterilization counseling about how the procedure does not prevent transmission of HIV and other sexually transmitted diseases, several Female Health Workers said that they were not aware of any HIV-related information they needed to provide to women before or after sterilization. When specifically asked whether they or the other outreach workers explained the risk of HIV to couples and counseled them to engage in safer sex even after sterilization, they said they were not aware of this.

Health workers told Human Rights Watch that both they and their male counterparts actively seek out women for sterilization because they “found it easier to convince women than men” to be sterilized.

Targeting Families with Sons, Larger Families
The preference for sons remains one of the most complex challenges for family planning in India. Families from Gujarat told Human Rights Watch that they preferred sons because of their capacity to do agricultural work and because they could support parents in old age, and felt girls get married and go away to their in-laws’ homes. Women who have borne sons are sought out by health workers as prime candidates for sterilization, sometimes without their informed consent.

Health workers from two districts of Gujarat told Human Rights Watch they targeted women who had already given birth to sons. One ASHA who was herself under pressure from her supervisor to be sterilized said she did not want to undergo the procedure because she had only one son, who was very young. She said that she approached women who had already had sons, and that most families prefer to have at least two sons before they agree to sterilization. Another ASHA said, “I tell women you have had two boys so you can get the operation done.” The Center for Health and Social Justice and Manjari, a nongovernmental organization, has also found that health workers target families with sons for female sterilization in Rajasthan.

In addition, health workers said Gujarat state’s unwritten two-child norm influenced whom they targeted for sterilization. A few health workers said that doctors from public and private hospitals told them to press women who had already had two live births to be sterilized. ASHAs from two villages said they conducted a survey to find families that had more than two children, and went to those homes to encourage women to be sterilized.

Indian health rights activists have repeatedly underscored the importance of tackling son preference and old age security effectively, while implementing family planning programs. Most recently, Indian experts from across the country reiterated the need to abandon the small-family norm and address social security for the elderly at the national conference on family planning in June. Activists at the conference cited sex-selective abortions as a danger of aggressively pursuing female sterilization and a small-family norm in the context of son preference.

Sterilization and IUD “Camps”
Many states in India perform sterilization en masse through “camps,” which involve using surgical facilities for one or more days for dozens of procedures. Recently, Tamil Nadu state also started conducting IUD camps.

In 2008, the Indian central government developed guidelinesfor “fixed day static services” to move away from the earlier method of conducting sterilization through periodic camps. However, these have actually resulted in what health workers now refer to as “weekly camps.” According to the 2008 guidelines, a district or block health facility should conduct 30 sterilization procedures every week. The 2008 guidelines supplement the Indian government’s 2006 Quality Assurance Manual for SterilizationServicesand the 2006 Standards for Female and Male Sterilization Services. These guidelines require that sterilizations be performed only with informed consent and counseling about possible complications, and require hygienic conditions and adequate equipment. Yet experts told Human Rights Watch that not all camps meet these requirements, sometimes resulting in complications from sterilization surgeries and even deaths.

Following orders of the Supreme Court in public interest litigation brought in 2003, the central government created an insurance plan to compensate families for deaths arising from female sterilization-related complications. But the focus on the numbers of women sterilized at these camps has overshadowed concerns about quality. Experts have repeatedly expressed concern that this insurance program is not being implemented properly and that quality continues to be a problem.

For example, in February 2012, a health rights activist from Bihar filed a public interest litigation with the Indian Supreme Court alleging lack of informed consent and poor quality services when 53 women were sterilized in Bihar state within two hours.

Health workers in Gujarat told Human Rights Watch that between 40 and 150 women are sterilized in weekly camps in their district. Dr. Abhijit Das from the Centre for Health and Social Justice, a leading Delhi-based health rights organization, told Human Rights Watch that he found at least one gynecologist in Madhya Pradesh state conducting 250 to 300 sterilizations on some days.

In one state, a study found that the state’s approach to female sterilization forced doctors in the public hospital to commit so much staff time to sterilization camps that other basic reproductive health care suffered. A civil society team that investigatedmaternal deaths in Barwani district of Madhya Pradesh state found that the senior gynecologist from the district hospital was absent four days in a week, performing sterilizations in camps.

Recent evidence suggests that the “camp” approach is being expanded for insertion of IUDs as well. A gynecologist from Tamil Nadu told Human Rights Watch that Tamil Nadu has started conducting camps in primary health centers for insertion of Copper-T IUDs. She told Human Rights Watch that camps in her district insert IUDs in 30 to 35 women a day. She expressed concern about the quality and availability of sterile equipment at primary health centers to handle this many procedures and also expressed concerns about informed consent.

Policies and Numerical Targets
India adopted a “Target-Free Approach” to Family Planning in 1996 and introduced the National Population Policyin 2000, which “affirms the commitment of government toward voluntary and informed choice and consent of citizens while availing of reproductive health care services, and continuation of the target free approach in administering family planning services.” The “target free approach” does not, in fact, eliminate targets, which were originally driven by the notion of populationstabilization. Even though on paper it leaves setting targets to states using a community-needs approach, little has changed on the ground.

Despite the policy’s stated commitment to reproductive health, informed consent, and choice of contraceptives, local experts have consistently criticized it for continuing “population control” and “population stabilization” as the approach for family planning. Experts from across the country at the June conference in New Delhi recommended that the Indian central government review the National Population Policy to shift its focus from demographics to individual rights.

Female sterilization continues to be the predominant method of family planning in India. The preference for female sterilization as a method of family planning is reflected in funding patterns, said the Centre for Health and Social Justice, based on its analysis of budgetary allocations for annual health plans for 2011-2012. Even states that have achieved replacement fertility continue to pursue female sterilization as a key contraceptive method. For example, recent health survey data shows that even states like Tamil Nadu– which has already achieved replacement fertility – pursue female sterilization as the predominant method, though it has recently shifted attention to IUDs using the camp approach.

Every state sets targets in its annual health plan for female sterilization, male sterilization, insertion of IUDs, and distribution of contraceptive pills. A central government body, the National Project Coordination Committee, reviews these targets and allocates funds for family planning in every state.

Sterilization targets are increased manifold at times. For example, Dr. Abhijit Das from the Centre for Health and Social Justice, found that in Bihar state fewer than 150,000 sterilization operations were “achieved” in 2005-2006 and the target for 2011-2012 was set at 650,000 – nearly a four-fold increase. Similarly, he told Human Rights Watch that Madhya Pradesh set a target of 700,000 for sterilization, doubling what was achieved in earlier years.

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